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AUTISM: IT’S NOT JUST A CHECKLIST

Children with autism spectrum disorder have impairments in reciprocal social interaction and social communication and restricted, repetitive interests and behaviors. The Centers for Disease Control and Prevention have reported that the estimated prevalence of autism spectrum disorder is 1 in 68 children aged 8 years; thus, autism spectrum disorder is 1 of the more common chronic medical conditions observed in pediatric medical practice. Unfortunately, rather than a focus on clinical judgment to diagnose and manage this common pediatric problem, in the era of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is periodically updated by the American Psychiatric Association, autism has become a checklist. Autism did not appear as a diagnosis in the DSM until the DSM-III was published in 1980. Subsequently, the DSM checklist criteria for autism have changed over time. In the DSM-IV-TR, which was published in 2000, to meet criteria for a diagnosis of “autistic disorder,” a child had to meet at least 6 out of a total of 12 checklist symptoms, with at least 2 criteria from a checklist of impairments in social interaction, at least 2 criteria from a checklist of impairments in communication, and at least 1 criteria from a checklist of restricted, repetitive, and stereotyped behaviors. A separate diagnosis of “Asperger disorder” was added to the DSM-IV (published in 1994), which included the same checklists for impairments in social interaction and restricted, repetitive, and stereotypic behaviors, but not the checklist of impairments in communication, as individuals with Asperger disorder were felt to have no delays in language development. However, the diagnosis of Asperger disorder was deleted from the DSM-5 (published in 2013). Currently, in the DSM-5, there is a single diagnosis of “autism spectrum disorder.” To meet DSM-5 criteria for “autism spectrum disorder,” a child must meet all 3 criteria from a checklist of persistent deficits in social communication and social interaction and at least 2 out of 4 criteria from a checklist of restricted, repetitive patterns of behavior, interests, or activities. The DSM-5 also requires (1) specification as to whether the autism spectrum disorder occurs with or without a language disorder, with or without an intellectual disability, or whether it is associated with a known medical or genetic condition or environmental factor; and (2) a rating of the severity level for both the impairment in social communication and the restricted, repetitive behaviors (level 1: requiring support; level 2: requiring substantial support; level 3: requiring very substantial support).

While this checklist approach to diagnosing autism spectrum disorder is considered by some to be the state of the art, the goal of this chapter is for pediatric medical providers to understand autism spectrum disorder within the entire spectrum and continuum of developmental-behavioral diagnoses, not as a simplified checklist. While autism itself presents with a wide spectrum of symptom severity and comorbidity, ranging from individuals with superior intelligence and mildly autistic behaviors to those with intellectual disability ...